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Z4 <br /> SAN JOAQUIN -LOCAL HEALTH DIS RR�CT <br /> FE OFk ICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466--6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date 'Issued Z—ZZ-Z�c <br /> (Complete In Triplicate) 1-31 - Zap-0-5- <br /> Application <br /> -c05Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. ' This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION CENSUS TRACT <br /> Owner's Name Phone , <br /> Address &.6- rya $ City ] �1, &W . <br /> i <br /> Contractor's Name ,> � � � � .� _ License # Phone Gle q�2S <br /> r <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN/-7 RECONDITION / / DESTRUCTION /-7 <br /> PUMP INSTALLATION / MP/ PUREPAIR ] (_PUMP REPLACEMENT /- <br /> Other /-7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY CID <br /> SEWAGE DISPOSAL FIELD r. CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial _ Cable Tool Dia. of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing <br /> - -- Irrigation Gravel Pack Depth of Grout Seal <br /> Other Rotary Type of Grout 4 <br /> Oth6r Other Information <br />+ PUMP INSTALLATION: Contractor <br />! Type of Pump r H.P. <br /> . s <br /> PUMP REPLACEhMNT. / / State Work Done <br /> PUMP `tEPAIR: State Work Done <br /> .DFRTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well 'construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br />'• 14ELL DRILLERS REPORT of the well and notify them before putting the..well in use. The above <br /> information is true to the best of my knowledge and belief. <br /> SIGNED �v.,1. AI.- A A;-U-tl TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> PHASE I <br /> APPLICATION ACCEPTED BY _ DATE <br /> ADDITIONAL CO1,MNTS: ~-i <br /> PHASE II GROUT INSPECTION PHASE I INSPECTION <br /> INSPECTION BY DATE INSPECTION BY DATE <br /> CALL FOR A GROUT INSPECTION PRIOR TO GROUTING AND FINAL INSPECT A <br /> E H 1426 5/731m <br />